Did your marital status change during the year?

Yes

No

Did your address change during the year?

Yes

No

Could you be claimed as a dependent on another person's tax return for 2019?

Yes

No

Were there any changes in dependents?

Yes

No

Were any of your unmarried children who might be claimed as dependents 19 years of age or older at the end of 2019?

Yes

No

Did you have any children under age 19 or full time students under age 24 at the end of 2019, with interest and dividend income in excess of $1,050, or total investment income in excess of $2,100

Yes

No

Did you and your dependents have health care coverage for the full year?

Yes

No

Did you receive any of the following IRS documents? Form 1095-A (Health Insurance Marketplace Statement), 1095-B (Health Care Coverage) or form 1095-C (Employer Provided Health Insurance Offer and Coverage)?

Yes

No

If you or your dependents did not have healthcare coverage during the year, do you fall into one of the following exemption categories: Indian tribe membership, health sharing ministry membership, religious sect membership, incarceration, exempt non-citizen or economic hardship?

Yes

No

Did you receive unreported tip income of $20 or more in any month?

Yes

No

Did you cash any Series EE US savings bonds issued after 1989 and pay qualified higher education expenses for yourself, your spouse, or your dependents?

Yes

No

Did you receive any disability income?

Yes

No

Did you have any foreign income or pay any foreign taxes?

Yes

No

Did you start a business or farm, purchase rental or royalty property, or acquire an interest in a partnership, S corporation, trust, or REMIC?

Yes

No

Did you purchase or dispose of any business assets (furniture, equipment, vehicles, real estate, etc.), or convert any personal assets to business use?

Yes

No

Did you buy or sell any stocks, bonds or other investment property in 2019?

Yes

No

Did you purchase, sell, or refinance your principal home or second home, or did you take a home equity loan?

Yes

No

Did you make any residential energy-efficient improvements or purchases involving solar, wind, geothermal or fuel cell energy sources?

Yes

No

Did you have any debts canceled or forgiven?

Yes

No

Does anyone owe you money which has become uncollectible?

Yes

No

Did you receive a distribution from a retirement plan (401(l), IRA, SEP, SIMPLE, Qualified Plan, etc)?

Yes

No

Did you make a contribution to a retirement plan (401(k), IRA, SEP, SIMPLE, Qualified Plan, etc)?

Yes

No

Did you transfer or rollover any amount from one retirement plan to another retirement plan?

Yes

No

Did you receive a distribution from an Education Savings Account or a Qualified Tuition Program?

Yes

No

Did you, your spouse, or a dependent incur any tuition expenses that are required to attend a college, university, or vocational school?

Yes

No

Did you incur a loss because of damaged or stolen property?

Yes

No

Did you work out of town for part of the year?

Yes

No

Did you use your car on the job (other than to and from work)?

Yes

No

Did you apply an overpayment of 2018 taxes to your 2019 estimated tax (instead of being refunded)?

Yes

No

If you have an overpayment of 2019 taxes, do you want the excess applied to your 2020 estimated tax (instead of being refunded)?

Yes

No

Do you expect your 2020 taxable income and withholdings to be different from 2019?

Yes

No

Do you want to allocate $3 to the Presidential Election Campaign Fund?

Yes

No

Does your spouse want to allocate $3 to the Presidential Election Campaign Fund?

Yes

No

May the IRS discuss your tax return with your preparer?

Yes

No

Did you have an interest in or signature or other authority over a financial account in a foreign country, such as a bank account, securities account, or other financial account?

Yes

No

Did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust or did you have an interest in any foreign assets or accounts?

Yes

No

Was your home rented out or used for business?

Yes

No

Did you have a medical savings account (MSA), a Medicare + Choice MSA, or acquire an interest in an MSA or a Medicare + Choice MSA because of the death of the account holder? Or, were you a policyholder who received payments under a long-term care (LTC) insurance contract or received any accelerated death benefits from a life insurance policy?

Yes

No

Did you receive a distribution from an Achieving a Better Life Experience (ABLE) savings account?

Yes

No

Are you a member of the Armed Forces of the United States on active duty who moved pursuant to a military order related to a permanent change of station?

Yes

No

Did you engage the services of any household employees?

Yes

No

Were you notified or audited by either the Internal Revenue Service or the State taxing agency?

Yes

No

Did you or your spouse make any gifts to an individual that total more than $15,000, or any gifts to a trust?

Yes

No

Did your bank account information change within the last twelve months?

Yes

No

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Address *

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Address 2

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